Pharmacy Prior Authorization

Pharmacy PA Contacts

Toll-free: 877-537-0722
Fax: 877-537-0720

Mississippi Medicaid Prescribers

Registered Users
If you are a Mississippi Medicaid prescriber, submit your prior authorization requests through the Envision web portal for the most efficient processing.

• Submit prior authorization requests through the Envision web portal

At 4:00 PM CST September 30, 2016, submit your prior authorization requests through the Change Healthcare provider portal.

• Submit prior authorization request through the Change Healthcare provider portal

Those Without Web Portal Access
For Mississippi Medicaid prescribers who are unable to submit prior authorizations through the Envision web portal, fax your request to:

Change Healthcare MS Medicaid Pharmacy PA Unit
Fax: 877-537-0720

Drug Prior Authorization Forms

• Standardized Prior Authorization Form
• Standardized Prior Authorization Form Instructions

Manual Prior Authorization Criteria

• Ampyra
• Antipsychotics
• Akynzeo
• Corlanor
• Cosentyx
• Cresemba
• Entresto
• Farydak
• Irritable/short bowel syndrome (Amitiza, Fulyzaq, Gattex, Linzess,Lotronex, Relistor, Zorbtive)
• Jadenu
• Juxtapid
• Kalydeco
• Kynamro
• Movantik
• Orkambi
• Sivextro® (tedizolid phosphate) and Zyvox® (linezolid)
• Stribild
• Synagis 2016-2017
• Tybost
• Varubi
• Zontivity

Pharmacy Prior Authorization – Other Information and Forms

• Crossover Form B
• MedWatch Form
• Pharmacy Notification of Beneficiary’s Other Insurance Coverage
• Pharmacy Claim Form and Form Instructions

PA Criteria Archive

• Bydureon PA criteria – 2/1/2012-3/31/2015